Patients' perceptions and views of surgery and radioiodine ablation in the definitive management of Graves' disease.

BACKGROUND: Patients' perceptions and preferences influence the choice of radioiodine ablation (RIA) or surgery in the definitive management of Graves' disease. This study aimed to evaluate their concerns, experiences and satisfaction following definitive treatment. METHODS: A postal survey of patients who had treatment with surgery or RIA between January 2011 and June 2013 for Graves' disease was conducted. RESULTS: Of 214 patients, 136 (64%) responded. The majority of patients felt actively involved in decision making (83.8%) and were satisfied (84.9%) with their treatment. Compared with RIA, patients who underwent surgery were more satisfied with their treatment (p=0.008). Discussion with the doctor was the most useful aid to decision making. Feeling involved in decision-making process was associated with improved satisfaction (p<0.001).Common reasons for not choosing surgery were need for general anaesthesia, scarring and voice change. Avoiding close contact, risk of persistent hyperthyroidism and worsening eye disease were common reasons for not choosing RIA. Ongoing concerns were hypothyroidism, scarring and eye problems after surgery and hypothyroidism and eye problems after RIA. CONCLUSIONS: This study provides insight into patients' experiences of surgery and RIA for Graves' disease and reinforces the importance of patient involvement in the decision-making process.

Parafibromin, galectin-3, PGP9.5, Ki67, and cyclin D1: using an immunohistochemical panel to aid in the diagnosis of parathyroid cancer.

BACKGROUND: Parathyroid cancer is rare. Differentiating parathyroid carcinoma from degenerative changes at histopathology can be difficult and studies investigating the value of single immunohistochemical markers have had variable results. In this study we aimed to investigate whether a panel of immunohistochemistry markers could aid the diagnosis of parathyroid cancer. METHODS: All cases of parathyroid cancer at our institution from 1998 to 2012 were identified retrospectively. Cases were classified as definite cancers (those with evidence of metastatic spread) or histological cancers (those with features of carcinoma without evidence of metastasis). Controls with benign parathyroid disease were included for comparison. Immunohistochemistry for parafibromin, galectin-3, PGP9.5, Ki67, and cyclin D1 was analysed by an experienced endocrine pathologist. RESULTS: There were 24 cases and 14 benign adenomas. Four cases had evidence of metastatic spread and 20 were diagnosed on histological criteria alone. Sixteen of the 24 cases had further surgery with ipsilateral thyroid lobectomy and 15 also had a prophylactic level VI lymph node dissection. Apart from one patient with distant metastases at presentation, none developed recurrence at follow-up (median = 38 months). Immunohistochemistry results associated with parathyroid cancer were seen in 11/24 parafibromin, 13/24 galectin-3, 8/24 PGP9.5, 5/24 Ki67, and 2/24 cyclin D1. None of the controls had immunohistochemical staining suggestive of cancer. Nineteen of the 24 patients had at least one immunohistochemical result associated with parathyroid cancer (sensitivity 79 %, specificity 100 %). Cyclin D1 did not suggest malignancy in any case that did not already have another abnormal marker, and so did not add value to the panel in this study. CONCLUSION: A panel of immunohistochemistry (PGP9.5, galectin-3, parafibromin, and Ki67) is better than any single marker and can be used to supplement classical histopathology in diagnosing parathyroid cancer.

Clinical Presentation and Outcomes of Phaeochromocytomas/Paragangliomas in Neurofibromatosis Type 1.

Introduction: Patients with neurofibromatosis type 1 (NF1) are at risk of developing phaeochromocytomas/paragangliomas (PHAEO/PG). Unlike in other familial PHAEO/PG syndromes, there are no published guidelines regarding screening in asymptomatic or normotensive patients with NF1. This strategy may be associated with preventable morbidities in those patients who ultimately present with symptomatic PHAEO/PG. Objective: To describe the mode of presentation and the incidence of adverse clinical outcomes attributed to PHAEO/PG in NF1. Methods: A retrospective study was performed in a tertiary referral centre in collaboration with a national complex NF1 centre. Hospital records and databases between 1998-2018 were searched. Results: Twenty-seven patients with NF1 and PHAEO/PG were identified. In all but one, PHAEO/PG was diagnosed after NF1. The median age at the time of diagnosis of PHAEO/PG was 43 years (range 22-65) and 21/27 (78%) were females. The diagnosis was mostly incidental in 13/27 (48%) while classical PHAEO/PG symptoms were found in 15/27 (56%), and hypertension was found in 14/27 (52%) of NF1 patients prior to PHAEO/PG diagnosis. No patient had undergone biochemical screening for PHAEO/PG. Metastatic disease was evident in 2/27 patients, 8 suffered potentially avoidable complications attributed to PHAEO/PG (including two deaths). Conclusion: The course of PHAEO/PG in NF1 is associated with an unpredictable presentation and potentially avoidable adverse outcomes. We recommend that routine biochemical screening for PHAEO/PG should be part of the care package offered to all patients with NF1 by regular measurements of plasma free or urinary fractionated metanephrines starting from early adolescence and repeated every 3 years.

Optimal Management of a Synchronous Diagnosis of Phaeochromocytoma and Colorectal Neoplasia.

The incidence rates of phaeochromocytoma and colorectal cancer (CRC) are approximately 1 and 65 per 100,000 per year, respectively. Simultaneous presentation of these conditions is rare and poses unique management challenges. We report on treatment strategies and clinical outcomes in a series of patients with colorectal neoplasia and phaeochromocytoma. Demographic and clinical details of four patients over a 4-year period were reviewed. The median (range) age at first presentation was 66 (52-70) years. Phaeochromocytoma (2.5-12.5 cm) was confirmed on biochemistry after incidental detection of an adrenal mass on CT scan-three had CT for staging of CRC and one had CT scan for weight loss. Adrenalectomy (three retroperitoneoscopic and one open procedure) was first performed after maximally tolerated alpha blockade; no significant complications were observed. Normalisation of biochemistry was confirmed and the patients then underwent colorectal surgery-laparoscopic right hemicolectomy, open right hemicolectomy (with further extensive surgery) for locally advanced cancer, laparoscopic low anterior resection and open high anterior resection. One respiratory infection and a seroma were the post-operative complications seen. In patients with a simultaneous diagnosis of phaeochromocytoma and CRC, surgical interventions should be staged. Adrenalectomy should first be performed to avoid haemodynamic instability during colorectal resection. A retroperitoneoscopic approach to the adrenal in patients with ipsilateral colonic tumours avoids transgressing the planes for colorectal resection. The synchronous diagnosis of these two rare conditions and the reported stimulatory effect of catecholamines on colorectal epithelia raise the possibility of an increased incidence of colorectal neoplasia in patients with phaeochromocytoma.

Surgery for breast cancer in the elderly--how relevant?

Studies suggest that elderly women receive less aggressive treatment, experience higher disease progression and mortality from breast cancer. We report on an experience of 256 consecutive cases of symptomatic breast cancer in a population of over 75 years of age. 142/256 patients underwent surgical intervention in the form of breast conserving surgery or mastectomy, 114/256 did not. Mean follow up was 6.4 years. Our results show a statistically significant association between surgery and survival (p = 0.05, CI 0.00046-0.19641) and a strong statistically significant association between surgery and disease progression/recurrence (p = 0.001, CI 0.08713-0.03145). Women treated conservatively are significantly less fit hence suffering high cancer unrelated mortality; as a consequence they suffer higher disease related progression and mortality. In our study surgical treatment with adjuvant endocrine and/or radiotherapy was associated with a statistically significant advantage in terms of disease related mortality and local disease control.